OBJECTIVE: To test the efficacy of Problem Adaptation Therapy for Pain (PATH-Pain) versus Usual Care (UC) in reducing pain-related disability, pain intensity, and depression among older adults with chronic pain and negative emotions. DESIGN: RCT assessing the between-group differences during the acute (0-10 weeks) and follow-up (weeks 11-24) phase of treatment. SETTING: A geriatrics primary care site. PARTICIPANTS: 100 participants (80 % females, Mean Age = 75.5) with chronic pain, negative emotions, and varying cognition (56 % had cognitive impairment) were randomly assigned to PATH-Pain (N = 49) or UC (N = 51). INTERVENTIONS: PATH-Pain is a collaborative program which includes a psychosocial intervention designed to improve emotion regulation. UC participants received a booklet that described evidence-based self-management pain strategies. MEASUREMENTS: Primary outcomes: Pain-related disability (Modified Roland-Morris Disability Questionnaire), and pain intensity. SECONDARY OUTCOMES: Depression (Montgomery-Asberg Depression Rating Scale), emotion regulation (Emotion Regulation Questionnaire), and treatment satisfaction (Client Satisfaction Questionnaire). RESULTS: During acute treatment (by Week 10), PATH-Pain vs. UC participants showed a significant decrease in pain-related disability [contrast mean difference (CMD) = -1.96, P = 0.02), CI [-0.47, -3.44]] and in depression severity (CMD = -2.50, P = 0.03, CI [-.0.23, -4.76]), but not in pain intensity. PATH-Pain (vs. UC) participants also demonstrated a significant improvement in expressive suppression, an aspect of emotion regulation (CMD = 2.120, P = 0.010, CI [.085, 4.155]). During follow-up (Week 11 to 24), there were no significant between-group differences in pain-related disability, pain intensity, or depression severity. CONCLUSIONS: This primarycarebased study demonstrates the short-term efficacy of PATH-Pain versus UC in reducing pain-related disability and depression in older adults with comorbid chronic pain and negative emotions, as well as varying degrees of cognitive functioning.